Provider Demographics
NPI:1073925087
Name:UDAWATTA, THIRAN (MD)
Entity Type:Individual
Prefix:
First Name:THIRAN
Middle Name:
Last Name:UDAWATTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2979 SQUALICUM PKWY STE 203
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1813
Mailing Address - Country:US
Mailing Address - Phone:360-733-7670
Mailing Address - Fax:360-647-1901
Practice Address - Street 1:2979 SQUALICUM PKWY STE 203
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1813
Practice Address - Country:US
Practice Address - Phone:360-733-7670
Practice Address - Fax:360-647-1901
Is Sole Proprietor?:No
Enumeration Date:2014-05-25
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61031268207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2154392Medicaid
WA440477OtherWA LABOR & INDUSTRIES